Healthcare Provider Details

I. General information

NPI: 1982962924
Provider Name (Legal Business Name): LAKE MI MOBILE DOCTORS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 E HIGHWAY 290 SUITE E-103
AUSTIN TX
78723-1068
US

IV. Provider business mailing address

3319 N ELSTON AVE SUITE 200
CHICAGO IL
60618-5811
US

V. Phone/Fax

Practice location:
  • Phone: 512-452-2100
  • Fax: 512-452-2106
Mailing address:
  • Phone: 773-751-7200
  • Fax: 773-583-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TYSYN CONTRERAS
Title or Position: DIRECTOR OF QUALITY ASSURANCE
Credential:
Phone: 312-939-5090